A case posted to the IDS forum by Phillips Alison

age: 65 years

sex: male

location: nail finger 2, left

Clinical history: Patient can't recall any trauma. Vague on history, but lesion present at least 6 - 8 months he thinks.

Diagnosis: Subungual haematoma?

Pyne John (7/16/2009 2:20:26 PM): Blood.

If due to trauma alone [patients often do not remember the event, or be aware of the event at all] it would not stay for 6 to 8 months.

Could be bleed from tumour [eg deeper glomus tumor] but unlikely. More likely the stated history is not right - but it may be, if it's not just trauma.

Plan = no biopsy today. Review in 5 to 6 weeks, expect by then the blood would begin to clear as the nail grows out.

Fox Gary (7/16/2009 2:24:50 PM): globules of blood . . .

Muir James (7/16/2009 2:59:01 PM): Blood, pare down nail till get pigment, submit for histology [dry not in formalin].

In older people with slow growing nails these last longer.

TZALOKOSTAS VASILIOS (7/16/2009 4:07:46 PM): Globules of blood....pare down nail till get pigment.. i agree.-

Zalaudek Iris (7/17/2009 8:50:46 AM): hemorrhage without doubts!

Giuseppe Argenziano (7/17/2009 8:55:41 AM): I agree

Fox Gary (7/17/2009 5:32:01 PM): I'm unclear - what is the benefit of paring and obtaining histology? Is there sufficient uncertainty clinically or for learning or ????

Campos do Carmo Gabriella (7/20/2009 10:09:19 PM): Alison, I think it's just blood, but as the patient doesn't mention any recent trauma and the evolution is a little longer, I suggest you follow up 2/2 months, just to see the blood going out and to see the normal subungueal plate.

Subungual hemorrhage

Nail hemorrhage frequently occurs following trauma to the nail. Patients seeking the advice of a physician because of subungual hemorrhage never recall any trauma or even think of the possibility of a trauma, because otherwise they would not seek consultation. The main clinical differential diagnoses of subungual hemorrhages are subungual nevi, subungual melanomas and, rarely, infections with fungi or bacteria, e.g. pseudomonas.

Clinically, subungual hemorrhages are characterized by variously sized, round to oval, sharply circumscribed, usually jet-black areas.
 At dermoscopic examination the jet-black clinical pigmentation appears lighter and reveals a red-black or even dark-red color, suggestive of hematoma. Moreover, adjacent to the sharply demarcated, structureless, dark red areas, some tiny, roundish, reddish dots may be recognized that on clinical examination are not visible.